Release R01 Candidate’s Permission to Release Psychological Assessment Information Candidate:
___________________________ ___________________________ _____________________ First Middle Last
Address:
___________________________________ ____________________ ______ ______________ Street City State Zip
Best Contact #
(________) ____________ - _____________
Email:
_______________________________________________________________________________
District:
[__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR
DCOM meeting: __________________________ Month
[__] Cell [__] Home [__] Work
____________________ ___________ Day Year
Acknowledgement: ___________ Candidate Initial here
Having met with the DCOM / BOM / Cabinet on the aforementioned date and having been required by the DCOM / BOM / Cabinet to seek counseling on matters raised in my psychological assessment, I hereby give permission for my psychological assessment to be shared with the following counselor for purposes of meeting the counseling requirement of the DCOM / BOM / Cabinet.
Counselor:
___________________________ ___________________________ _____________________ First Middle Last
Address:
___________________________________ ____________________ ______ ______________ Street City State Zip
Best Contact #
(________) ____________ - _____________
Email:
_______________________________________________________________________________
[__] Cell [__] Home [__] Work
Acknowledgement: ___________ Candidate Initial here
I also give permission to the above named counselor to share the outcome and / or substance of the counseling session(s) with the DCOM / BOM / Cabinet in order for the DCOM / BOM / Cabinet to make a more informed decision regarding my qualifications and desire to become a certified candidate for ministry. I understand that the counselor will be submitting a written report to the DCOM and that the DCOM / BOM / Cabinet may ask questions of the counselor in an attempt to further clarify the issue(s) for which the counseling was conducted.
__________________________________ Candidate Signature __________________________________ DCOM / BOM / Cabinet Signature
__________________________________ Printed Name __________________________________ Printed Name
Copies of this Release are to be placed in the Candidate’s DCOM file and the Counselor’s file: [__] Chair, DCOM [__] BOM Representative [__] Dean, Cabinet [__] Counselor
___________________ Date ___________________ Date
Updated: 2020-11